Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0200, written 20 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jun 2023 |
|---|---|
| Reference | 2023-0200 |
| Deceased | Michael Sullivan |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Stockport Integrated Care Partnership 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 22nd December 2022 I commenced an investigation into the death of Michael Brian Sullivan. The investigation concluded on the 16th May 2023 and the conclusion was one of Narrative: Died of natural causes exacerbated by lithium toxicity. The medical cause of death was 1a) Bronchopneumonia; II) Bipolar disorder, Lithium toxicity, chronic obstructive pulmonary disease 4 CIRCUMSTANCES OF THE DEATH Michael Brian Sullivan had schizophrenia and was bipolar. He took lithium medication. He deteriorated at his home address and was admitted to Stepping Hill Hospital after concerns were raised by his family. He was found to have pneumonia and lithium toxicity, a complication of his bronchopneumonia and related to his dehydration. He deteriorated despite treatment and died at Stepping Hill Hospital on 17th December 2022. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The evidence before the inquest was that Mr Sullivan was a vulnerable person with a complex mental health history. The inquest heard evidence 1 that GPs could access a Crisis Review Team to assess patients such as Mr Sullivan. However, the evidence before the inquest was that there seemed to be delays between referrals and assessments. It was unclear if these were due to a lack of understanding by GPs on how the CRT could be used or how patients were prioritised within the CRT or a lack of effective triage by GPs before referral or the CRT following referral. In his case the concern was raised by his family on 13th December 2022 with the GP. The GP referred him to the CRT that day indicating he needed an assessment on 14th December 2023 for confusion following a fall and a possible UTI. At the assessment on 14th December 2023 at 11am Mr Sullivan was seriously unwell. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) Metropolitan Borough Council, who may find it useful or of interest. and 2) Stockport I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Alison Mutch HM Senior Coroner 20.06.2023 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Date: Ms A Mutch HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Michael Brian Sullivan 17th December 2022 Thank you for your Regulation 28 Report dated 20/06/2023 concerning the sad death of Michael Brian Sullivan on17/12/2022. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Mr. Sullivan’s family for their loss. Thank you for highlighting your concerns during Mr. Sullivan’s Inquest which concluded on 16th May 2023. On behalf of NHS GM, I would like to thank you for bringing these matters of concern to our attention so we can make the necessary improvements to the quality and safety of future services. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken. The medical cause of death was: Bronchopneumonia; Bipolar disorder, Lithium Toxicity, Chronic Obstructive Pulmonary Disease. I hope the response below demonstrates to you and Mr. Sullivan’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system. This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case. The evidence before the inquest was that Mr Sullivan was a vulnerable person with a complex mental health history. The inquest heard evidence that GPs could access a Crisis Review Team to assess patients such as Mr Sullivan. However, the evidence before the inquest was that there seemed to be delays between referrals and assessments. It was unclear if these were due to a lack of understanding by GPs on how the CRT could be used or how patients were prioritised within the CRT or a lack of effective triage by GPs before referral or the CRT following referral. In his case the concern was raised by his family on 13th December 2022 with the GP. The GP referred him to the CRT that day indicating he needed an assessment on 14th December 2023 for confusion following a fall and a possible UTI. At the assessment on 14th December 2023 at 11am Mr Sullivan was seriously unwell. The aim of the Crisis Response Team (CRT) is to reduce unnecessary hospital admissions and prevent avoidable Emergency Department (ED) attendances by providing holistic multidisciplinary intervention and support in order to stabilise patients in their own home or usual residence. The service is available 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk for patients registered with a Stockport General Practitioner (GP) aged 18 or over. They are a multi-disciplinary integrated team consisting of highly skilled senior nurses, occupational therapists (OT), physiotherapists, Social Workers and support workers, in collaboration with the Mental Health Liaison Team. They take referrals from any professional (GP, District Nurse, Social Worker or North West Ambulance Service). A CRT registered professional will triage the referral and ensure the patient is allocated to the appropriate member of the team; a nurse, OT, physiotherapist or social worker, with this initial assessment being carried out within 2 hours of the referral into the service. They will also assess patients who are in the emergency department or the clinical decision unit if it is deemed appropriate. To prevent a hospital admission, they have access to a range of community resources and support options. The aim of the service is to stabilise patients within 72 hours. If ongoing support is needed after this, then referrals are made for support from the appropriate services in the neighbourhoods. Patients with an Enhanced Case Management Plan or patients who have accessed CRT previously can access CRT directly. In this case I can confirm the following:- • There were no delays between referral to CRT and assessment at the time of this referral. • The referral request from the GP specified requirement for an assessment to be completed the following day (14 December 2022); Mr Sullivan was confirmed to be safe at home overnight • Had the GP requested an assessment on 13 December 2022, the service would have been able to provide an immediate response and would have attended Mr Sullivan at his home on the same day. The consultation note added to the clinical system within the GP practice has been reviewed. This captures the discussion that took place between the GP and the patient and between the GP and the patient’s brother on 13th of December 2022. Mr Sullivan was reported to appear confused following a fall; Mr Sullivan had the Carecall service in place (this is a 24-hour telemonitoring and response service that provides support to people who wish to remain independent in their own home) and they reported that he may have a urinary tract infection. The GP made arrangements for a routine home visit for Friday 16th of December but also referred to CRT to request assessment the following day. Safety netting advice (this is information given to a patient or their carer during a primary care consultation, about actions to take if their condition fails to improve, changes or if they have further concerns about their health in the future), was given to the patient and brother, they were advised to call NHS111 or access emergency services in the event of any deterioration overnight. Whilst the GP acted appropriately in requesting support via CRT and providing safety netting advice, as CRT were able to offer more timely response (they can respond within 2 hours), earlier assessment should have been considered. Actions taken or being taken to share learning across Greater Manchester: 1. Learning to be presented/shared with the Greater Manchester System Quality Group on 21st September 2023. This meeting is attended by commissioners, including commissioners of specialist services, localities, regulators, Healthwatch and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk services. 2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services. In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester. I hope this response demonstrates to you and Mr. Sullivans’s family that NHS GM has taken the concerns you have raised seriously and is committed to working together as a system including our service users, carers and families to improve the care provided. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely Chief Nursing Officer GM Integrated Care Stockport Place Based Lead GM Integrated Care 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
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